Neck Disorders Flashcards by Leslie Mancini

Laryngeal cancer

general

Squamous cell carcinoma is the most common subtype
Significant association with tobacco use
Linked to HPV type 16 & 18
More common in oropharyngeal cancer
Nonsmokers
Males aged 50-70 years

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laryngeal cancer

S/Sx

Change in voice quality persistent
Most common
Throat pain
Especially with swallowing
Ear pain
Especially with swallowing
Hemoptysis
Dysphagia
Weight loss
Airway compromise

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Laryngeal cancer

Full head and neck evaluation
Laryngoscopy

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Laryngeal cancer

Laryngoscopy

Evaluate
True fold mobility
Arytenoid fixation
Surface tumor extension
Sometimes, has bronchoscopy or esophagoscopy at same time
Evaluate for synchronous primary tumor
Biopsy

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Laryngeal cancer

imaging

CT or MRI neck
Goals
Extent of tumor
Tumor volume
Cartilage sclerosis
Cartilage destruction
Evaluate neck lymph nodes
CT Chest if:
Level IV or VI lymph nodes involved
Concerning chest x-ray
Concerns for metastases
Consider PET/CT if metastases

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larygeal cancer

Laboratory Evaluation

Complete blood count
Liver function tests

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Laryngeal Cancer

Biopsy during laryngoscopy
Need pathology of tumor
Mobility of true vocal cords
T1/T2 Glottic tumors with mobile true vocal cords < 5% node involvement
Immobile folds up to 30% nodal involvement
TNM Staging

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laryngeal cancer

Tx goals

4 Goals
Cure
Preservation of safe and effective swallowing
Preservation of useful voice
Avoidance of permanent tracheostoma

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Early glottic/supraglottic cancer

Radiation therapy is standard of care
>95%/80% cure rates
Significant morbidity

Some tumors may consider partial laryngectomy
Locoregional cure rates 80-90%
Even those with clinical N0 disease benefit from elective limited neck dissection
High risk of neck lymph node involvement, especially supraglottic tumors

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Stage III/IV

Chemo Tx

Advanced Stage (III/IV)
Treatment is challenging
Concurrent radiation therapy with Cisplatin based chemotherapy currently utilized most frequently
Superior to either modality alone
Now may consider epidermal growth factor receptor (EGFR) inhibitor Cetuximab (Erbitux)
Lower overall systemic toxicity
Better tolerated

Both systemic agents in combination with XRT are associated with
prolonged gastrostomy-tube dependent dysphagia
Laryngeal stenosis

Select patient may be able to have frontline surgical intervention
Referral to medical oncology, radiation oncology, and surgical oncology (specializing in head and neck dissections-typically tertiary centers)

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Laryngectomy

Total laryngectomy
Advanced resectable tumors with
extra laryngeal spread
Cartilage involvement
Persistent tumor following chemoradiation
Recurrence after primary treatment
2nd primary tumor following previous radiation therapy
Speech options
Tracheoesophageal puncture produces successful speech in 75-80%
Indwelling prostheses, changed every 3-6 months

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laryngeal cancer

follow up

65% cure rate
3-4% annual second primary rate
Risk for recurrence
Psychosocial Issues
Altered appearance
Work
Social interactions
Medical conditions
Dysphagia
Impaired communication

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Vocal Cord Paralysis

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Unilateral vocal fold paralysis

Causes

Due to
Lesion
Damage to vagus nerve
Skull base tumors
Damage to recurrent laryngeal nerve
Unilateral
Thyroid surgery
Neck surgery
Anterior discectomy
Carotid endarterectomy
Mediastinal or apical lung cancer involvement
Cricoarytenoid arthritis
Advanced rheumatoid arthritis

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Unilateral Vocal Cord Paralysis

general

May be temporary
Up to a year for spontaneous resolution
Surgical intervention for persistent/irrecoverable symptomatic disease
Goals
Medialization of paralyzed vocal fold
Create stable platform for vocal fold vibration
Advancing diet
Improving pulmonary toilet
Cough

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Uniulateral Paralysis of vocal folds

Surgical Interventions cont.

Injection laryngoplasty with Teflon, Gel foam, fat, or collagen
Teflon only permanent injectable material
Avoid due to risk of granuloma formation on vocal cords

Formal medialization thyroplasty
For permanent paralysis

Formal medialization thyroplasty
Create a small window in thyroid cartilage
Place implant between the thyroarytenoid muscle and inner table of the thyroid cartilage
Moves the vocal fold medially
Creates a stable platform for bilateral, symmetric mucosal vibration

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Bilateral Vocal Cord Paralysis

General
Breathing pattern

Inspiratory stridor with deep inspiration Emergency
Create safe airway with tracheostomy
Minimal reduction in voice quality
Aspiration prevention
Tracheostomy creation

Insidious onset
Asymptomatic at rest
Normal voice

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Bilateral Vocal Cord Paralysis

etiology

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Etiology
Esophageal cancer
Thyroid surgery
Ventricular shunt malfunction
Cricoarytenoid arthritis
Intubation injuries
Glottic and subglottic stenosis
Laryngeal cancer

Tracheostomy

Indications

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Airway obstruction at or above the level of the larynx
Respiratory failure requiring prolonged mechanical ventilation
Most common reason
No consensus on # of days
Life threatening aspiration pneumonia
Improve pulmonary toilet
Related to insufficient clearing of tracheobronchial secretions
Sleep apnea

Tracheotomy Options

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Bedside tracheotomy (in ICU)
More cost effective
Percutaneous dilational tracheotomy
Bedside procedure
Tracheotomy with videobronchoscopy in OR
Reduce complications

Tracheostomy

complications

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Subglottic stenosis
Extended endotracheal intubation
Dislodging of tracheotomy tube

Tracheotomy

care

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Humidified air
Prevent secretions from crusting and occluding inner cannula of the tracheotomy tube

Clean several times per day

Frequent tracheal/bronchia suctioning
Increased bronchial secretions and aspiration of saliva
Elevation of larynx required for swallowing which is limited by tracheotomy

Stoma skin care
Prevent maceration and secondary infections

Cricothyrotomy

general

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In emergency situations, secures a faster airway than tracheostomy
Fewer complications
Pneumothorax
Hemorrhage

# Cric

# Tracheal Foreign Bodies general

Aspiration of foreign bodies more common in children Adults at greatest risk are denture wearers and older adults Diagnosis (if required) Chest x-ray Radiopaque foreign body If radiolucent Inspiration & expiration film Air trapping distal to obstruction Flattened diaphragm Later, atelectasis and pneumonia

# trachea foreign body Tx

Treatment Heimlich maneuver Cricothyrotomy Rigid bronchoscopy under general anesthesia

# Congenital Neck Masses Branchial Cleft Cysts

Soft cystic mass along anterior border of the sternocleidomastoid muscle Benign congenital cysts lined by epithelial cells Seen usually in 20s-30s May see sudden swelling or infection

# Branchial Cleft Cyst Types

First branchial cysts High in the neck May have fistula extending to floor of the external auditory canal Second branchial cleft cysts *Most common* May communicate with the tonsillar fossa Third branchial cleft cysts *Rare* Low in the neck May communicate with the piriform sinus

# Branchial Cleft Cyst Dx

Ultrasound CT MRI

# Branchial Cleft Cyst Tx

Treatment Surgical excision with removal of fistulous tracts Prevents recurrent infections and possible carcinoma

# Thyroglossal Duct Cysts general

Along the embryologic course of thyroid’s descent from the tuberculum impar of the tongue base in the low neck Most common before age 20 Can occur at anytime Midline neck mass usually just below the hyoid bone Moves with swallowing

# Thyroglossal Duct Cysts Tx

Surgical excision recommended Prevent recurrent infection Involves removing Fistulous tract Middle portion of hyoid bone Many fistulas pass through here Preoperative thyroid ultrasound recommended Confirm anatomic position of thyroid

Thyroglossal duct cyst

# Reactive Cervical Lymphadenopathy

Normal lymph nodes **< 1cm** Neck lymphadenopathy can commonly be due to infections involving Pharynx Salivary glands Scalp Common in HIV patients Treatment Directed at underlying source If suppurates, incision & drainage (I&D) of lymph node

# Cervical LAD when to worry

When to worry Lymph node > 1.5cm Lymph node with necrotic center (with no obvious infection) Especially with history of Tobacco use Alcohol use Prior cancer Persistent lymphadenopathy Continued enlargement

# cervical LAD Dx 4

How to evaluate Ultrasound Fine needle aspiration (FNA) Culture Pathology

# Cervical LAD Causes 3

Tumor Squamous cell carcinoma Lymphoma Metastatic disease from non head & neck area Infection Reactive Mycobacteria Cat-scratch disease Autoimmune disease Kikuchi disease (histiocytic necrotizing lymphadenitis)

# Granulomatous Neck Masses general

Incidence increasing Both immunocompromised and immunocompetent patients Typical presentation Single or matted lymph nodes May extend to skin and drain externally (late presentation) Scrofula (mycobacterium adenitis)

# Granulomatous Neck Masses Causes 3

causes Mycobacterial adenitis Sarcoidosis Cat-scratch disease (Bartonella henselae)

# Granulomatous Neck Masses Dx

Diagnosis FNA (88% sensitivity, 49% specificity) Cytology Smear for acid-fast bacilli Mycobacterial culture PCR in some cases Excisional biopsy often required to confirm diagnosis

# Tumor Metastases general

In older adults, 80% of firm, persistent, and enlarging neck masses are metastatic disease Majority from squamous cell carcinoma of upper aerodigestive tract Physical exam may reveal source Consider Laryngoscopy Esophagoscopy Bronchoscopy

# Tumpor metastases Dx

FNA vs. open biopsy Diagnostic imaging MRI PET

# Supraclavicular Lymphadenopathy Source

Lung cancer Gastric cancer Esophageal cancer Breast cancer

# Lymphoma general

10% of lymphomas present in head & neck Multiple rubbery lymph nodes in young adults Needs open biopsy (NOT FNA)

Neck Disorders Flashcards

(45 cards)